(Relocation) by a74abaf35cd8e297


									                                                                             TRAVEL VOUCHER (Relocation)
1. TRAVEL AUTHORIZATION NO.                2. SOCIAL SECURITY NO.            3. NAME (Last)                                              (First)                                          (Middle Initial) 4. AGENCY

5. AGENCY ORIGINATING OFFICE               6. TRAVELER ORIGINATING                     7. DATES OF TRAVEL EXPENSES                                          8. TYPE CLAIM (Indicate one type only)    9. RECLAIM
   NUMBER                                     OFFICE NUMBER                                      FROM                               THRU                           HH = Hsehunting SR = Supp RIT         AMOUNT
                                                                                         Month    Day     Year   Month               Day           Year                                                  INCLUDED
                                                                                                                                                                   TS = Trans Stn    OT = Outside
                                                                                                                                                                   RC = Relo Contr         Cont. U.S.
                                                                                                                                                                   RI = RIT                Transfer
10. DATE REPORTED AT NEW                   11. LEAVE TAKEN                                          12. OFFICIAL DUTY STATION CITY AND STATE                    13. RESIDENT CITY AND STATE (If other than official station)
                                                     Y = Yes   N = No
  Month           Day          Year        14. TOTAL NIGHTS LODGING                                 15. NUMBER OF NIGHTS IN APPROVED ACCOMMODATIONS PER THE FIRE SAFETY ACT STANDAR                                      DS

SECTION B -- TRAVEL VOUCHER MAILING ADDRESS OPTIONS                                                                                                             SECTION D -- CLAIMS
          16. SALARY ADDRESS          17. T&A CONTACT POINT              18. SPECIAL ADDRESS                   19. TRAVEL EFT ACCOUNT   26. TOTAL SALES PRICE OF FORMER RESIDENCE                           $
                                                                                                                                        27. TOTAL PURCHASE PRICE OF NEW RESIDENCE                           $

1. (35)                                                                                                                                 28. EXPENSES CLAIMED BY RELOCATION SERVICES
                                                                                                                                            COMPANY (For Type Claim RC Only, Invoice Attached)
                                                                                                                                        a. APPRAISED VALUE SALES FEE                           $
2. (35)                                                                                                                                 b. AMENDED VALUE SALES FEE                                          $

                                                                                                                                        c. CANCELLATION FEES                                                $
3. City (20)                                                     State (2)                      Zip Code (9)                                                  EXPENSES CLAIMED BY EMPLOYEE
SECTION C -- TRANSPORTATION COSTS                                                                                                       29. OUTSIDE CONT. U.S. SUBSISTENCE (Type Claim OT Only)                          0.00
    20.              21.                       22.                    23. CAR RENTAL                                                                 LOCATION
METHOD OF          VENDOR/               IDENTIFICATION                                                 24.                                                                               NO. OF                AMOUNT
                                                                                                      AMOUNT                                                                              DAYS
 PAYMENT           CARRIER                  NUMBER                    MILES        DAYS                                                             CITY                             ST

                                                                                            $             0.00                                                                                       $

If payment was made by traveler,
complete Section G on reverse.                     TOTALS            0             0        $             0.00                                       TOTAL OUTSIDE CONT. U.S. SUBSISTENCE $                        0.00
25. AIRLINE ACCOMMODATIONS                                                                                                              30. REAL ESTATE (Paid by Employee)                         AMOUNT           NFC USE
                                               Excess fare (Check if applicable)                    Non-contract (Insert Code)
                                                                                                                                        a. SALES EXPENSE (AD-424 Attached)                    $
                                                                                                                                        b. PURCHASE EXPENSE (AD-424 Attached)
           50. AUTHORIZATION ACCOUNTING (Check this block if accounting from travel
           authorization is to be charged for the total voucher claim.)                                                                 c. LEASE TERMINATION EXPENSE
           51. DISTRIBUTED ACCOUNTING (Check this block and distribute total claim from Section D to                                    31. PER DIEM
           the applicable Accounting Classification line.)                                                                                     No. of Days [ 0.00 ] LODGING & IE
PURPOSE CODE                                     ACCOUNTING CLASSIFICATION                                            PERCENTAGE           No. of Travelers [     ] MEALS                                0.00
                                                                                                                                        32. MILEAGE
                                                                                                                                    %              Rate [               ¢] Miles [ 0.00 ]
                                                                                                                                                   Rate [               ¢] Miles [      ]
                                                                                                                                                           Rate [       ¢] Miles [        ]
                                                                                                                                                           Rate [       ¢] Miles [        ]
                                                                                                                                        33. PARKING, TOLLS, ETC.                                         0.00
                                                                                                                                        34. PLANE, BUS, TRAIN (Paid by Traveler)                         0.00
                                                                                                                                        35. UNACCOMPANIED BAGGAGE                                        0.00
                                                                                                                                        36. LOCAL TRANSPORTATION                                         0.00
                                                                                                                                        37. MISCELLANEOUS EXPENSES/
                                                                                                                                            ALLOWANCE                                                    0.00
                                                                                                                                        38. CAR RENTAL                                                   0.00
                                                                                                                                        39. SHIPMENT OF HOUSEHOLD GOODS
                                                                    THESE PERCENTAGES MUST EQUAL                         100%
                                                                                                                                                   Total Weight     [                     ]              0.00
SECTION F -- CERTIFICATION                                                                                                              40. STORAGE OF HOUSEHOLD GOODS                        1ST 30 DAYS
FRAUDULENT CLAIM. Falsification of an item in an expense account will result in a forfeiture of the claim (28 USC
2514) and may result in a fine of not more than $10,000 or imprisonment for not more than 5 years or both (18 USC 287; i.d.
1001).                                                                                                                                             Total Weight     [                     ]   OVER 30 DAYS

CLAIMANT'S RESPONSIBILITIES AND SIGNATURE. I hereby assign to the United States any rights I may have                                       No. Days [                                    ]
against other parties in connection with any reimbursable carrier transportation charges described herein. I have received no
                                                                                                                              41. TEMPORARY QUARTERS (AD-569
payment for claims shown herein. All travel and reimbursable claims were incurred on official business of the United States
Government. All tickets, coupons, promotional items and credits received in connection with travel claimed on this voucher
                                                                                                                                             No. of Days [                                ]
have been accounted for as required by FPMR 101-7 and other regulations. I have reviewed this voucher and certify it to be
correct.                                                                                                                                  No. Occupants [                                 ]
52. CLAIMANT'S SIGNATURE                                                       53. DATE                    54. FINAL VOUCHER
                                                                               Month Day          Year         INDICATOR                42. RELOCATION INCOME TAX
                                                                                                                  Y = Yes N = No            (AD-1000 Attached)

APPROVING OFFICER'S RESPONSIBILITIES AND SIGNATURE. In approving this voucher, I have determined that: (1) 43.                                            TOTAL CLAIM
Reimbursement is claimed for official travel only; (2) Use of rental car, taxicab, or other special conveyance for which reimbursement is claimed            (Block 29 thru 42)        $                 0.00
is to the Government's advantage; and (3) Long distance phone calls and supplies or equipment purchased are necessary and in the interest of
the Government. Note: To approve long distance phone calls, approving officer must have written authorization from Agency Head or his /her
                                                                                                                                                  44. TRAVEL ADVANCE AMOUNT
designee (31 USC 1348).
55. APPROVING OFFICER'S SIGNATURE                                                                                 56. SOCIAL SECURITY NO.
                                                                                                                                                  45. AMT. OF VOUCHER (Block 43) TO BE
                                                                                                                                                      APPLIED TO OUTSTANDING ADVANCE
                                                                                                                                                      (Block 44)
57. NAME AND TITLE (Last, First, Middle Initial) (Type or Print)                                                                  AGENCY
                                                                                                                                  CODE            46. AMT. OF VOUCHER (Block 43) TO BE
                                                                                                                                                      APPLIED TO OUTSTANDING BILL FOR
58. DATE APPROVED 59. PHONE (Area Code and No.)
Month Day         Year                                                                                                                            BILL NO.
                                                                                                                                        47 ADDITIONAL ADVANCE AMOUNT
60. CONTACT PERSON                                                                               61. PHONE (Area Code and No.)             REPAID (Check or Money Order

                                                                                                                                        48 REMAINING ADVANCE BALANCE
           Upon completion and approval, submit original voucher to:                                                                       (Block 43 minus Blocks 45 and 47)                             0.00
             U.S. Department of Agriculture                                                                                             49.
                                                                                                                                               NET TO TRAVELER
             National Finance Center                                                                                                    (Block 43 minus Blocks 45 and 46)                     $          0.00
             P.O. Box 60000                                                                                                             AUDITED BY                                            TOTAL DIFFERENCE
             New Orleans, LA 70160                                                                                                                                                                                     0.00
                                                                                                                                                                                   FORM AD - 616R (USDA) (Rev. 11/96)
                                                                                                                                              This form was electronically produced by National Production Services Staff
                                                                                                                                                                               Exception to SF 1012 approved by GSA 11/20/96
                                                                                                         Clear Form

        ITINERARY                                                                                                                                                     TOTALS

DATE (Month/Day)
                                                                                                                                                                   these totals to
                                                                                                                                                                   Section D on
                                                                                                                                                                   Voucher Front.

             TO                                                                                                                                                     If additional
DATE (Month/Day)                                                                                                                                                      days are
CITY                                                                                                                                                               required, use
COUNTY                                                                                                                                                              continuation
STATE                                                                                                                                                                  sheet

         PER DIEM                                                                                                                                              TOTAL NO. DAYS

NO. OF DAYS                                                                                                                                                                     0.00
LODGING & INCIDENTAL                                                                                                                                           TOTAL LODGING & IE
(Receipt Required for Lodging)                                                                                                                                 $                0.00
                                                                                                                                                               TOTAL MEALS

MEALS                                                                                                                                                          $               0.00
         MILEAGE                                                                                                                                               TOTAL MILES


RATE PER MILE                                     ¢                    ¢                ¢          ¢                 ¢                 ¢                  ¢                     0.00
                                                                                                                                                               TOTAL MILEAGE

MILEAGE AMOUNT                             0.00               0.00               0.00           0.00            0.00               0.00              0.00      $                0.00
                                                                                                                                                               TOTAL PARKING

PARKING, TOLLS, ETC.                                                                                                                                           $                0.00
                                                                                                                                                               TOTAL PLANE, BUS,
   PLANE, BUS, TRAIN                                                                                                                                           TRAIN
     (Paid By Traveler)                                                                                                                                        $               0.00
                                                                                                                                                               TOTAL UNACCOMPANIED
   UNACCOMPANIED                                                                                                                                               BAGGAGE
      BAGGAGE                                                                                                                                                  $               0.00
       LOCAL                                                                                                                                                   TOTAL LOCAL
   TRANSPORTATION                                                                                                                                              TRANSPORTATION
DAILY EXPENSE                                                                                                                                                  $                0.00
   MISCELLANEOUS                                                                                                                                               TOTAL
       EXPENSES/                                                                                                                                               MISCELLANEOUS
      ALLOWANCE                                                                                                                                                $                0.00
      CAR RENTAL                                                                                                                                               TOTAL CAR RENTAL
     (Paid by Traveler)
   Receipt and Car Rental
    Agreement Required
GASOLINE EXPENSE                                                                                                                                               $
SHIPMENT OF HOUSEHOLD GOODS PAID BY TRAVELER (Weight Certificate or Bill of Lading Required)
TOTAL WEIGHT OF                  COMMUTED RATE                        TOTAL                                     ADDITIONAL ALLOWANCES                          TOTAL SHIPMENT AMOUNT
GOODS SHIPPED                    X                                =                                    0.00 +                                                 =$
                                                      NUMBER OF       TOTAL       ACTUAL    COMMUTED        CLAIM LESSER AMOUNT AND                            1ST 30 DAYS AMOUNT
                                                      DAYS            WEIGHT      CHARGES   RATE            DISTRIBUTE TO APPLICABLE PERIOD                    $
                                                      CLAIMED         OF GOODS              CHARGES         OF STORAGE
       TEMPORARY STORAGE                                                                                                                                       OVER 30 DAYS AMOUNT

                                                                                 $          $             $                                                    $

PRIVACY ACT NOTICE. The following information is provided to comply with the Privacy Act of 1974 (P.L. 93-579). The information requested on this form is required
under the provisions of 5 USC, Chapter 57 (as amended) and Executive Orders 11609 of July 22, 1971, and 11012 of March 27, 1962, for the purpose of recording travel expenses
incurred by the employee and to claim other entitlements and allowances as prescribed in the Federal Travel Regulations (41 CFR 301-304). The information contained in this form
will be used by Federal Agency officers and employees who have a need for such information in the performance of their duties. Information will be transferred to appropriate
Federal, State, local or foreign agencies, when relevant to civil, criminal, or regulatory investigations or prosecutions or pursuant to a requirement by GSA or such other agency in
connection with the hiring or firing, or security clearance, or such other investigations of the performance of official duty in Government service. Failure to provide the information
required will result in delay or suspension of the employee's claim for reimbursement.

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